Discussion
Management of right-sided IE affecting the TV includes medical versus surgical management, with intravenous antibiotics as the cornerstone treatment for this condition. 3 However, surgical intervention, such as valve replacement, valve repair, and valvectomy may be warranted in several situations including persistent infection, large valve vegetations, and right-sided heart failure secondary to severe TV regurgitation. 3 Despite similar survival outcomes, valve repair is preferred to valve replacement due to freedom from reoperation and lower pacemaker implantation. 3Due to concerns about developing right-sided heart failure and its association with in-hospital stroke, renal failure, and mechanical ventilation, valvectomy has been recommended as a bridge to valve repair or replacement. 4
Despite its risks, valvectomy may be an appropriate intervention in patients with persistent sepsis, extensive lesions, and abscess.3 A staged valvectomy before valve replacement has also been recommended in patients with ongoing drug use with concerns for inconsistent follow-up and poor IVDU abstinence. This gives providers time to manage addiction and other psychosocial morbidities before valve replacement. 5 Valvectomy is generally contraindicated in patients with pulmonary hypertension and right-sided heart failure due to severe tricuspid regurgitation. 5Despite the existence of this contraindication in our patient, we pursued valvectomy to get source control of the persistent infection. Concomitant arterial-venous ECMO helped with right-sided decompression and optimizing systemic perfusion.
While not common practice, urgent ECMO can be used as a bridge to diagnosis and corrective surgery in patients who develop comp licationspost tricuspid valvectomy. In one case, an undiagnosed or newly developed PFO in the patient resulted in right to left shunting and subsequent refractory hypoxemia post tricuspid valvectomy.6 ECMO gave providers time to diagnose the PFO on imaging and appropriately prepare patients for corrective surgery. In our case, ECMO was a planned procedure, allowing the clearance of bacteremia and preventing further complications from VSD and right-sided heart failure in preparation for definitive management.
High-risk repeat surgery for endocarditis secondary to IVDU recidivism is an ethically controversial topic. As recidivism is the leading cause of mortality in patients who undergo surgical management, some providers consider repeat surgery psychosocially futile. 2,7 As follows, strategies such as the “three-strike approach” have been proposed. This is a contract in which the patient agrees to appropriate follow-up and addiction management with only two chances of surgical interventions. Others believe that because prosthetic valves, unlike donor organs, are not a scarce resource, healthcare professionals should not limit treatments on the basis of patient adherence to lifestyle recommendations. 8 Our institution does not restrict the number of reoperations for recurrent prosthetic valve endocarditis, as long as they are surgical candidates from an operative risk standpoint. Furthermore with a multidisciplinary IVDU Addiction Team in place, consisting of addiction medicine physicians, social workers, infectious disease physicians, psychiatrists, cardiac surgeons, nutritionists, pain service specialists, physical therapists, and cardiologists, our postoperative follow-up success continues to improve. Therefore, this has allowed us to not refrain from helping patients with IVDU recidivism. On follow-up care 2 months later, our patient was in rehab and remained asymptomatic.